Earlier this month, Affinity shared a glimpse into the state of reproductive health in Mississippi, Missouri and Georgia. These three states are among many that have come under fire for their restrictive abortion policies, as well as their perceived shortcomings in maternal and child health. Now, we return to Alabama and Arkansas to discuss state policy, health and sex education, and other structures that impact the health of mothers and infants in these states.
Alabama has come under fire numerous times due to their treatment of pregnant women, most recently including their indictment of Marshae Jones on manslaughter charges after she was shot, which led to the death of her unborn child. Additionally, controversy ensued when lawmakers rejected an amendment to their abortion law which would allow the practice in cases of rape or incest. However, how does this treatment translate into healthcare?
First, like other states at the forefront of the reproductive health debate, Alabama has a large rural population, with 55 counties considered rural and 12 classified as urban. These counties are then further classified by their geographic position (like Rural North) or degree of “ruralness.” Alabama declined federal funds to expand Medicaid, meaning that there may be coverage gaps for people who need it. However, there are still programs in place to assist those in need, and many of the state’s practices are backed by research.
In part one of this series, I referenced the fact that unintended pregnancies were more likely to result in problems like low birth weight or preterm delivery due to a lack of preparation for the situation. The 2015 PRAMS report states that 49.6 percent of births during that year were unintended and approximately 7.2 percent of pregnancies were unwanted. The highest percentage of unintended pregnancies occurred among women who already had at least two children, and the birth was at least their third child. 64.3 percent of births to women on Medicaid were unintended, compared to 33.1 percent of women who were not on Medicaid. The report notes what percentage of mothers participated in programs like WIC (54.6 percent), had medical problems (64.9 percent), showed signs of postpartum depression (8.9 percent felt down all the time while 48.5 percent felt down sometimes or rarely) or continued smoking or drinking regularly during pregnancy (11 and 5 percent respectively). It also notes practices like whether the mother received dental care during pregnancy or if they breastfed their child or laid them down on their backs to sleep. Thus, state programs created for maternal and infant health often focus on health education and ensuring access to resources.
Similar to the programs instituted in Mississippi, Missouri and Georgia, Alabama has implemented the “Plan First” program, a family planning initiative for women ages 19 to 55. Plan First is intended to provide access to underserved women, who benefit from yearly exams, support from social workers and nurses, birth control, pregnancy and STI testing, and planning pregnancies. Sterilization for men and women is also offered above the age of 21, but informed consent has to be given at least 30 days in advance. The state Medicaid division also provides general family planning services for “females of childbearing age, 8 [eight] through 55” and sexually active men of all ages. Provided services include initial visits, annual visits, four periodic revisits per year, one home visit 60 days postpartum, one extended postpartum consultation, pregnancy tests, STI tests, Pap smears, urinalysis and general bloodwork. Birth control methods that are covered include pills, jellies, diaphragms, creams, IUDs, injections, and implants. Removal of long-acting contraceptives like IUDs are not covered by family planning insurance, even if it is for a medical reason. Hysterectomies are not covered by either Plan First or the Family Planning program.
So, how is this program being utilized? The 2018 Plan First report revealed that participation in the demonstration decreased between 2017 and 2018, but noted that this was potentially due to more patients enrolling in Insurance Affordability Plans instead. This reveals that there are at least multiple options for low-income patients to receive reproductive care, but whether these options are sufficient for Alabama residents is another question.
In terms of education, the state health department shares various educational resources relating to family planning, ranging from fact sheets on contraceptives to guides on how to discuss puberty, abuse, birth control and other topics with loved ones. The state also instituted WHI-FI, or the “Women’s Health Information for the Incarcerated” program, which provides health resources and education to incarcerated women as a joint partnership between the Aid to Inmate Mothers organization and the Department of Public Health Office of Women’s Health. Incarcerated women can learn about HIV, sexually transmitted infections, human sexuality and various conditions that can impact maternal and infant health. They can also get referrals for birth control, STI screenings, cancer early detection programs and WIC services among other services.
The outlook on education for teens is a bit more variable; the Guttmacher Institute says that Alabama does not mandate sex education in schools, but HIV education is mandatory. When sex education is offered, abstinence must be stressed, and LGBT people are portrayed in a negative light. The state also manages ARPREP, a federally funded teen pregnancy prevention program. ARPREP funds five community-based programs to prevent pregnancy and STI transmission, and it intends to teach teenagers about healthy relationships, adolescent development, and the development of healthy values.
One of the most notable things about reproductive health in Alabama is the emphasis on HIV transmission. To reduce perinatal HIV transmission, all pregnant women are tested for HIV in accordance with CDC guidelines. HIV prevention guidelines also encourage preconception counseling for HIV-positive women and state that “all HIV-infected women contemplating pregnancy should be on a maximally suppressive antiretroviral regimen”. The state also takes care to discourage premastication, or pre-chewing food to give to infants, although the risk of HIV transmission through saliva is low. All babies born to an HIV-positive mother have to be tested for HIV at birth and must take antiretroviral drugs for up to 6 weeks. This is not for no reason – in 2016, there were approximately 13 new cases of HIV in Alabama per 100,000 residents. This is also likely the reason why HIV education is mandated in the state.
Arkansas faces “geographic maldistribution” of medical professionals, and over 500,000 residents live in health professional shortage areas (HPSAs). Out of 75 counties, 36 are primary care HPSAs, 20 are dental HPSAs, and 69 are mental health HPSAs. A large number of residents are uninsured, and as 20 percent of adults read at or below a 5th-grade level, health literacy is limited.
In a sharp contrast to the other states examined in this series, neither sex education nor HIV education are mandated in Arkansas (which reflects in the fact that 46 percent of survey respondents who became pregnant in 2017 were using the withdrawal method as a form of birth control). An attempt to pass a sex education bill in 2019 failed after lawmakers attempted to add amendments barring the participation of Planned Parenthood. If sex ed is offered, it must stress abstinence, as the state wants to “discourage sexual activity among students”, despite the fact that not talking about sex does not discourage it from occurring. School districts can establish health clinics for students, but they cannot use state funds to purchase contraceptives for students and the student must have parental consent to receive contraceptives from the clinic. The CDC had previously identified 16 critical sexual education topics (now 19), and only 20 percent of Arkansas schools taught all 16 in 2017.
However, despite the pitfalls in education, there are some bright spots. The state health department provides low-cost or no-cost prenatal, postpartum and counseling services to women via local health units. Family planning services are available in all counties, including contraceptives, physical exams, pap smears, STI testing and other lab tests, education, counseling and referrals. There are also several community health centers designated to eliminate health disparities in the state. Officials have also partnered with organizations like Sisters United and Brothers United to support the health of black communities, and anyone who goes through the proper training can become a lay midwife. Some goals of the health department are to reduce teen birth rate, improve neonatal hospital care and prevent unplanned pregnancy. The health department website also tracks successes in changing hospital policy to support infant health.
In addition to WIC, all pregnant women within the income threshold are eligible for Medicaid. 52.2 percent of pregnant women got prenatal care covered by Medicaid or ARKids First in 2017. However, Arkansas seems to lack the various family planning waivers that can be found in other states.
Most of the pitfalls in Alabama and Arkansas stem from legislation rather than the implementation of state programs. Both states are showing progress, but of course, part of the job still falls to lawmakers.
There is no doubt that the state of reproductive health in the U.S. is bleak—maternal mortality is still high, especially among black women, and the recent abortion bans have created more anxiety. However, health professionals and advocates are still working to ensure that pregnant people and children receive the care that they deserve. In May, the Alabama Women’s Center said they would continue to provide care for as long as they could, and state health departments continue to play a major role in ensuring the health of the nation as a whole. In times like these, it may be difficult to remain optimistic, but one thing that we need to remember is that we are not alone in our fight. When we invest in education and adequate healthcare, we invest in healthy families and a better society.